Spotlight on the value of care

One recent study found overtreatment of type 2 diabetes among elderly patients, while
another looked at how many patients with diabetes would be referred to a liver specialist
under proposed European guidelines.

Two recent European studies looked at situations in which current screening and treatment
might be excessive for patients with type 2 diabetes.

The first study, published by Diabetes, Obesity and Metabolism on Jan. 24, included 1,002 Dutch patients with type 2 diabetes. Among the 319 patients
who were age 70 years or older, the median HbA1c level was 7.0%; 30.1% had macrovascular
complications, and 50.8% had microvascular complications. Using an algorithm from
Dutch guidelines, these patients were classified into three subgroups by HbA1c target.
Focusing specifically on the patients age 70 years and older who had an HbA1c target greater than 7%, the study found that 38.8%
were overtreated (that is, they had a HbA1c level below their target). Hypoglycemia occurred in 20.3%
of these patients, and almost 30% had reported falls. The study authors concluded
that a substantial number of older patients with type 2 diabetes may be overtreated,
even after they have reported hypoglycemia and falls to clinicians. “Care professionals
should abandon the ‘one size fits all’ approach and realize the possible
benefits of de-intensifying blood glucose-lowering treatment. To prevent overtreatment,
a lower HbA1c limit in the guidelines might be helpful. Diabetes quality indicators
should not be based on population-based mean values, because means will overlook under-
and overtreatment completely,” the authors said.

The second study, published by Diabetic Medicine on Jan. 10, examined the potential impact of recently proposed recommendations on diagnosis of non-alcoholic fatty liver
disease from the European Association for the Study of the Liver, European Association for
the Study of Diabetes, and European Association for the Study of Obesity. Researchers
assessed 179 patients with type 2 diabetes, finding that 68.7% had steatosis according
to proton magnetic resonance spectroscopy. Applying the guidelines and various combinations
of scores, including the fatty liver index, non-alcoholic fatty liver disease fibrosis
score, Steatotest score, and FibroTest score, they calculated that 33.5% to 84.9%
of the patients would be referred to a liver clinic. “It would not be possible
to refer such a high proportion of people with Type 2 diabetes to a liver clinic,”
the study authors wrote. “We suggest that new clinical and/or biological biomarkers
of steatosis and fibrosis be specifically validated in people with Type 2 diabetes.”

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Diabetes Monthly provides a monthly summary for internists about relevant news in diabetes. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.